The world population is aging and people are living longer than ever before. Consequently patients are living with a wide range of ophthalmic and systemic health conditions, many of which have varying effects on vision. Gathering clinical data can be more difficult with elderly patients, compared with younger patients. Dementia, impaired hearing, visual and physical handicaps, such as impaired mobility, often limit and complicate communication and successful completion of a range of appropriate clinical investigations. Thus, obtaining an effective history demands increased clinical skills, time, extra patience, reliance on family members or carers for relevant information and maintaining good accurate clinical records that document all relevant findings and information. As a result of the patient's decreased mobility and agility, ophthalmic examination is often more time-consuming and challenging, particularly with frail elderly patients.
Undertaking an eye examination with an elderly patient, whilst maintaining the highest professional clinical standards, may require a number of adaptations to the range of clinical investigative techniques routinely used, as well as significant modifications to methods of communication. The clinician therefore should ideally be able to undertake competently a range of advanced clinical investigative techniques, where appropriate, in addition to routine clinical techniques. This is so that potential ocular signs of systemic and ophthalmic conditions that may be present are not missed. Failing to identify certain clinical signs may lead to a missed or incorrect diagnosis. Also, not being able to perform certain advanced clinical investigations may lead to otherwise unnecessary referral of patients.
Hypertension & heart disease
Hypertension is classified by the following levels of blood pressure (BP):
- Stage 1: 140/90
- Stage 2: 160/100
- Sage 3 (severe): 180/110
Blood pressure (BP) measurement can be very useful in a number of clinical scenarios and optometrists should consider undertaking, or at least be familiar with how to take BP measurements in order to improve the quality of referrals when required. The simplest way is to use a BP machine that automatically measures BP once a cuff has been inflated on the arm, just above their elbow, of the seated patient.
2014 2.9 million people with diabetes
2025 > 5 million
90% Type 2 Diabetes mellitus
10% Type 1 Diabetes mellitus
DR present within 20 years of diagnosis
Most diabetics undergo annual diabetic screening using digital photography. However for some diabetics, particularly frail elderly patients, or those with significant media opacities, digital imaging may not be possible. Good slit lamp biomicroscopy skills are therefore needed and competence in using a number of binocular indirect ophthalmoscopic techniques. In addition to slit lamp biomicroscopy and Volk lens indirect ophthalmoscopy, head set indirect ophthalmoscopy can be advantageous for fundus examination through dilated pupils in elderly patients with poor mobility. Even using a portable slit lamp biomicroscope may be required. Although clinically very useful in certain situations e.g. viewing disc new vessels (NVDs), relying on just direct ophthalmoscopy to examine these diabetic patients is no longer considered sufficient.
The two main types of stroke are either haemorrhagic or ischaemic. Depending on where they occur, strokes may affect the visual pathway. The simplest method of visual field assessment in such cases is confrontation in order to pick up field defects such as homonymous hemianopia or quadrantanopia. This is a simple test often overlooked or not performed adequately enough to pick up such field defects so this should be practised routinely to maintain proficiency. Ensuring a good clinical history is also important in diagnosing stroke and looking out for other key clinical signs e.g. facial weakness, arm weakness, speech problems and time since onset of symptoms (FAST).
Malignant disease (cancers)
Malignant disease (cancer) is common in elderly patients and many may be receiving chemotherapy and/or radiotherapy. Melanoma is the most common form of ophthalmic malignant disease with 450 new cases per year. The prevalence of this condition increases with age with people over 50 years more commonly affected. It is vital that these cases are picked up early, which requires competence in thorough fundus examination - including the use of three mirror gonio lenses and head set binocular indirect ophthalmoscopy for checking the peripheral retina. Secondary metastatic tumours may also affect the eyes and these may also be picked up using routine as well as more advanced clinical techniques.
Smoking related disease (AMD)
It is always important to enquire about smoking and also to explain the consequences of smoking to patients such as nuclear sclerotic cataract and age related macular degeneration (AMD). Differentiating dry AMD from wet AMD is very important and unnecessary referrals can be avoided if the appropriate clinical investigations are properly conducted such as Volk lens indirect ophthalmoscopy macular assessment, checking for any areas of elevation signifying a retinal pigment epithelial detachment (PED) for example. In wet AMD symptoms typically include rapid onset visual loss, distortion and a central blind spot. Appropriate use of an Amsler chart at the very least or ideally having access to optical coherence tomography (OCT) to confirm the presence of sub-retinal or intra-retinal fluid can make accurate, appropriate and timely referrals much easier for subsequent treatment.
The two main types of arthritis include osteoarthritis and rheumatoid arthritis (RA). RA is commonly associated with iritis and 25% of RA patients have dry eyes leading to Sjögrens. Uveitis is more common in younger patients. Good slit lamp biomicroscopy and dry eye assessment skills are important e.g. tear prism height and tear break up time (TBUT), as is the ability to check for signs of uveitis (flare, cells, KPs). Occasionally with dry eyes, punctal plugs may be indicated (see clinical techniques section to view this procedure).
This is a progressive degenerative neurological condition that affects mobility, coordination and gait. Initially a fine tremor may be noted and later this develops into a course tremor. Ocular palsies affecting the eyes are common with Parkinson’s and therefore a full ocular motility assessment is important. Despite apparently good VA, impaired visual function is common with difficulties reading. Patients may experience visual hallucinations. Blepharospasm, decreased blink rate and decreased convergence amplitudes are also often found.
The most common type of dementia is Alzheimer’s, followed by vascular dementia, then Lewy body dementia and fronto temporal dementia. Dementia is often undiagnosed causing varying disturbances of cognition which may result in difficulty sensing motion, depth, colour and contrast. Glaucoma may develop more rapidly in patients with Alzheimer’s and drusen may increase significantly at the macula so the clinician needs to be vigilant in their clinical investigations.
As the population ages, Alzheimer’s is becoming increasingly common. It has been estimated that there are 1 in 1400 of 40-65 year olds; 1 in 100 of 65-69 years olds; 1 in 25 of those over 70 and 1 in 6 of those over 80 years living with Alzheimer’s.
1. Enquiry into mental health status of patients with dementia
Careful inquiry into the mental health status of elderly patients is most important in view of the high incidence of dementia and depression among the elderly. Optometric assessment of people with dementia is often more difficult owing to their inability to concentrate, with varying levels of confusion leading to an inability to adequately comply with an eye examination. Visual perceptual problems experienced are due to neurological damage, which are often overlooked during a standard eye examination. Among the early signs of dementia in older people are the gradual loss of memory and the progression of impairment of judgment and logical reasoning. Only later in the course of the disease does disorientation become a major difficulty. If the ophthalmic examination provides any suggestion of functional cognitive impairment, it is wise for the optometrist to verify the accuracy of other aspects of clinical history with relatives and carers of the patient. By asking the patient to describe a typical day, the clinician can frequently glean important information about the patient's interests, social activities, and eating habits, for example. Delving into the daily routines of an elderly patient (particularly those with signs of dementia) gives important clues about the level of independent living an individual enjoys and helps prioritise the need for referral for interventions such as cataract surgery for example.
Any deficits, real or perceived, point to the need for more in-depth evaluation and/or a closer look at the patient's support network. Appropriate referral to an eye clinical liaison officer (ECLO) is often very helpful in such cases.
2. Modification of clinical examination techniques for patients with dementia
For optimal clinic outcomes it is recommended to always have a carer or relative present with dementia patients who hopefully can provide useful information about the individual.
Some dementia patients also may find it comforting to bring a familiar object with them that they have an affinity for, as a point of reference during the eye examination.
Charles Bonnet Syndrome
Charles Bonnet syndrome (CBS) is a common condition among people who have lost their sight, particularly the elderly. It causes people who have lost a lot of vision to see things that aren't really there i.e. visual hallucinations. Exactly how sight loss leads to hallucinations isn't really known, but research is slowly revealing more about how the eye and the brain interact. It is only natural for patients to worry, or become confused or frightened when they experience visual hallucinations. Until they know what is actually happening, elderly patients may become concerned that seeing things is a sign of a mental health problem or that they have some form of dementia. There is no single test that can be undertaken to diagnose CBS. However, it is important to reassure elderly patients that CBS is caused by sight loss only and not by any other health problem.
Discussion of glaucoma is beyond the scope of this module however the advanced clinical techniques discussed here are relevant to the detection and diagnosis of glaucoma. In particular gonioscopy, applanation tonometry and pachymetry (to measure corneal thickness) in addition to non-contact tonometry (NCT) and visual field examination.